cvs caremark mail service order form guide - … mail service order... · cvs caremark mail service...
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CVS Caremark Mail Service Order Form GuideSimply follow these six steps to fill out your new mail service order form, and get started enjoying the convenience and savings of CVS Caremark Mail Service Pharmacy.
1. Fill in the ID Number. The ID
number is on your benefit ID card
and it identifies the card holder.
(On your next order, your ID number
will be pre-printed above this field.)
2. Fill in your address and phone
number in its entirety. Be sure to
fill in the oval if you want your
prescription mailed to a one-time
address.
5. Provide information for the first
person submitting a prescription.
• Indicate if you would like your order
to include Easy-Open Caps. Most
prescriptions have combination easy
open/safety caps. However, some
come only with safety caps, unless
easy-open caps are requested.
• Be sure to completely fill out your
Doctor’s First Name and Last Name
and Telephone Number.
• Fill in the ovals under Allergies if you
are allergic to any drugs or foods. If
you do not see the drug or food you
are allergic to, fill in the Other oval
and write it in.
• Fill in the ovals if you have any Health
Conditions. If you do not see your
health condition, fill in the Other
oval and write it in.
Note: It is only necessary to report allergies and health conditions the first time you submit a mail service order to CVS Caremark, or if there are changes.
3. Enter the name of your prescription plan sponsor or Company, i.e., the company that provides your prescription benefit plan.
4. For new prescriptions, simply enclose the original prescription(s) with your order form. For refills, write in the prescription number(s) in the spaces provided. When you receive your prescription order, a refill order form will be enclosed that will list your refills. Simply fill in the ovals for the prescriptions you want to refill.
5a. (OPTIONAL) Provide information for the second person if you are submitting prescriptions for two family members. If this is the case, provide the same information as in STEP 4.
6. Fill in the appropriate oval for your method of payment. If you are paying by check or money order, please write your ID number on the check. If you are paying by credit card, be sure to include your signature. Do not send cash. Regular delivery is free. Fill in an oval for optional expedited delivery.
7. Make sure you enclose the original prescription(s) you received from your doctor (not photo copies).
That’s It! Now, simply mail your order form along with your prescription(s) and payment in the envelope
provided to the address printed on the form. Be sure to fold the form on the lines indicated so
the address shows through the window of the return envelope.
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©2008 Caremark. All rights reserved. 49-9532f 12.08
3
Apt./Suite#
City State ZIP Code
SHIPPING ADDRESS IF NOT SHOWN OR DIFFERENT FROM ABOVE:
Enter ID# if not shown or different from above
Street Address
REFILL INFORMATION:
Use this addressfor this order only.
MAIL SERVICE ORDER FORM
-- --Daytime Phone #:
Prescription Plan Sponsor or Company Name
Evening Phone #:
Mail order form to:
Prescriptions sent in one envelope may be shipped together unless you request otherwise.
Last Name First Name MI Suffix (JR, SR)
©2008 Caremark. All rights reserved. P12-N
DIRECTIONS: Print in BLUE or BLACK ink, using CAPITAL letters. Fill in ovals completely ( ). Completeboth sides of form.
To order new prescriptions: Mail your prescription(s) with this form. # of new prescriptions:
To order refills: Order by Web, phone, or write in Rx number(s) below. # of refill prescriptions:FOR FASTEST SERVICE, order refills at www.caremark.com or call the number on your prescriptionbenefit identification card.
To order mail service refills, enter your prescription number(s) here:
1) 2) 3) 4)
5) 6) 7) 8)
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CVS CAREMARKPO BOX 2110PITTSBURGH PA 15230-2110
PGH STD
PGH-MOF-1208
1st PERSON ORDERING A PRESCRIPTION
Doctor’s First NameDoctor’s Last Name
FILL IN FOR UP TO TWO PEOPLE WHO WILL RECEIVE PRESCRIPTIONS WITH THIS ORDER
Easy open caps
Your E-mail:
Doctor’s Phone #
L A S T N A M E F I R S T N A M E MSuffix(JR,SR)
PAYMENT INFORMATION: Select one payment method below.
Check/Money Order: Amount $ Credit Card Holder Signature/DateM M Y Y
Charge most recently used credit cardCharge new/updated credit/debit card (provide info below)
Credit/Debit Card (VISA, MasterCard, Discover or American Express)
2nd Business Day $17 per order
REGULAR DELIVERY IS FREE(Allow up to 10 days for delivery)
.
C R E D I T C A R D #
Date of Birth:Gender: M F M M D D Y Y Y YN I C K N A M E
Bill Me Later® (Subject to credit approval. Please pre-register at Caremark.com or call Customer Care)
Electronic Check Processing (Please pre-register at Caremark.com or call Customer Care)
Print in Spanish
Date new prescription written:
2nd PERSON ORDERING A PRESCRIPTION
Doctor’s First NameDoctor’s Last Name
Easy open caps
Your E-mail:
Doctor’s Phone #
L A S T N A M E F I R S T N A M E M
ErythromycinALLERGY/HEALTH INFORMATION: COMPLETE ONLY IF CHANGED OR NOT PREVIOUSLY REPORTED
Conditions:
Cephalosporin CodeineAspirinNoneSulfa Other:
Peanuts Penicillin
Arthritis Asthma Diabetes Acid Reflux Glaucoma Heart ProblemHigh Blood PressureOther:
High Cholesterol Migraine Osteoporosis Prostate Issues Thyroid
Date of Birth:Gender: M FN I C K N A M E
Print in Spanish
Date new prescription written:
Allergies:
Special Instructions:
M M D D Y Y Y Y
Exp.Date
Make check or money order payable to CVS Caremark andwrite your ID# on the check/money order. Returned checkswill be subject to a fee of up to $40, depending on statelaw.The selected payment method (unless paying by check) willbe charged for future orders, unless a different form ofpayment is provided. It will also be charged for anyoutstanding balance due.
Fill in oval for faster delivery:
(Charges subject to change)Next Business Day $23 per order
Fill in oval if you DO NOT want the selected payment method to be automatically charged for future orders.
ErythromycinALLERGY/HEALTH INFORMATION: COMPLETE ONLY IF CHANGED OR NOT PREVIOUSLY REPORTED
Conditions:
Cephalosporin CodeineAspirinNoneSulfa Other:
Peanuts Penicillin
Arthritis Asthma Diabetes Acid Reflux Glaucoma Heart ProblemHigh Blood PressureOther:
High Cholesterol Migraine Osteoporosis Prostate Issues Thyroid
Allergies:
Suffix(JR,SR)
Faster delivery options only affect shipping time,not processing time and can only be sent to astreet address, not a P.O. box.
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